Differential effects of a school-based obesity prevention program: A cluster randomized trial
Nathan C Nickel, Malcolm Doupe, Jennifer E Enns, Marni Brownell, Joykrishna Sarkar, Dan Chateau, Elaine Burland, Mariette Chartier, Alan Katz, Leah Crockett, Meghan B Azad, Jon M McGavock, Robert Santos, Nathan C Nickel, Malcolm Doupe, Jennifer E Enns, Marni Brownell, Joykrishna Sarkar, Dan Chateau, Elaine Burland, Mariette Chartier, Alan Katz, Leah Crockett, Meghan B Azad, Jon M McGavock, Robert Santos
Abstract
School-based healthy living interventions are widely promoted as strategies for preventing obesity. The peer-led Healthy Buddies™ curriculum has been shown to improve obesity-related outcomes in school-aged children. We examined whether these improvements existed among subgroups of children stratified by sex, income level and urban/rural geography. In a cluster-randomized controlled trial, elementary schools in Manitoba, Canada, were randomly allocated to Healthy Buddies™ (10 schools, 340 students) or standard curriculum (10 schools, 347 students). Healthy Buddies™ participants had 21weekly lessons on healthy eating, physical activity and self-efficacy, delivered by children age 9-12 to children age 6-8. We assessed pre- and post-intervention body mass index (BMI) z-scores, waist circumference, healthy living knowledge, dietary intake and self-efficacy among the younger children. Compared to standard curriculum (n = 154), Healthy Buddies™ participants (n = 157) experienced a greater reduction in waist circumference (-1.7 cm; 95% confidence interval [CI][-2.8, -0.5 cm]) and improved dietary intake (4.6; 95% CI [0.9, 8.3]), healthy living knowledge (5.9; 95% CI [2.3, 9.5]) and self-efficacy (5.3; 95% CI [1.0, 9.5]) scores. In subgroup analyses, effects for waist circumference (-2.0 cm; 95% CI [-3.6, -0.5]), healthy living knowledge (9.1; 95% CI [4.4, 13.8]) and self-efficacy (8.3; 95% CI [3.3, 13.3]) were significant among boys. Dietary intake (10.5; 95% CI [5.5, 15.4]), healthy living knowledge (9.8; 95% CI [4.5, 15.0]) and self-efficacy (6.7; 95% CI [0.7, 12.7]) improved among urban-dwelling but not rural-dwelling children. Healthy Buddies™ was effective for boys and children living in urban settings. Enhanced curricula may be needed to improve program effectiveness for select subgroups of school-aged children.
Trial registration: ClinicalTrials.gov NCT01979978.
Keywords: childhood obesity; health outcomes; health promotion; healthy living intervention; inequalities; randomized controlled trial; school-based intervention; socio-economic factors.
Conflict of interest statement
The authors declare that they have no conflicts of interest.
© 2020 The Authors. Maternal & Child Nutrition published by John Wiley & Sons, Ltd.
Figures
References
- Baranowski, T. , Cullen, K. W. , Nicklas, T. , Thompson, D. , & Baranowski, J. (2002). School‐based obesity prevention: A blueprint for taming the epidemic. American Journal of Health Behavior, 26(6), 486–493. Retrieved from.
- Bleich, S. N. , Vercammen, K. A. , Zatz, L. Y. , Frelier, J. M. , Ebbeling, C. B. , & Peeters, A. (2018). Interventions to prevent global childhood overweight and obesity: A systematic review. The Lancet. Diabetes & Endocrinology, 6(4), 332–346. 10.1016/S2213-8587(17)30358-3
- Brown, T. , & Summerbell, C. (2009). Systematic review of school‐based interventions that focus on changing dietary intake and physical activity levels to prevent childhood obesity: An update to the obesity guidance produced by the National Institute for Health and Clinical Excellence. Obesity Reviews : An Official Journal of the International Association for the Study of Obesity, 10(1), 110–141. 10.1111/j.1467-789X.2008.00515.x
- Burke, R. M. , Meyer, A. , Kay, C. , Allensworth, D. , & Gazmararian, J. A. (2014). A holistic school‐based intervention for improving health‐related knowledge, body composition, and fitness in elementary school students: An evaluation of the HealthMPowers program. The International Journal of Behavioral Nutrition and Physical Activity, 11, 78 10.1186/1479-5868-11-78
- Cleland, C. L. , Tully, M. A. , Kee, F. , & Cupples, M. E. (2012). The effectiveness of physical activity interventions in socio‐economically disadvantaged communities: A systematic review. Preventive Medicine, 54(6), 371–380. 10.1016/j.ypmed.2012.04.004
- Curbing Childhood Obesity: A Federal, Provincial and Territorial Framework for Action to Promote Healthy Weights . (2012). Retrieved from
- Daniels, S. (2009). The use of BMI in the clinical setting. Pediatrics, 124(Supplement 1), S35–S41.
- Dietz, W. H. (1997). Periods of risk in childhood for the development of adult obesity—What do we need to learn? The Journal of Nutrition, 127(9), 1884S–1886S. 10.1093/jn/127.9.1884S
- Doak, C. M. , Visscher, T. L. S. , Renders, C. M. , & Seidell, J. C. (2006). Theprevention of overweight and obesity in children and adolescents:A review of interventions and programmes. Obesity Reviews : An Official Journal of the International Association for the Study of Obesity,7(1), 111–136. 10.1111/j.1467-789X.2006.00234.x
- Everson‐Hock, E. S. , Johnson, M. , Jones, R. , Woods, H. B. , Goyder, E. , Payne, N. , & Chilcott, J. (2013). Community‐based dietary and physical activity interventions in low socioeconomic groups in the UK: A mixed methods systematic review. Preventive Medicine, 56(5), 265–272. 10.1016/j.ypmed.2013.02.023
- Federal/Provincial and Territorial Advisory Committee on Population Health . (1994). Strategies for population health: Investigating the health of Canadians. Retrieved from
- Federal/Provincial and Territorial Advisory Committee on Population Health . (1999). Toward a healthy future: Second report on the health of Canadians. Retrieved from
- Flynn, M. A. T. , McNeil, D. A. , Maloff, B. , Mutasingwa, D. , Wu, M. , Ford, C. , & Tough, S. C. (2006). Reducing obesity and related chronic disease risk in children and youth: A synthesis of evidence with “best practice” recommendations. Obesity Reviews : An Official Journal of the International Association for the Study of Obesity, 7(Suppl 1), 7–66. 10.1111/j.1467-789X.2006.00242.x
- Fulton, J. E. , McGuire, M. T. , Caspersen, C. J. , & Dietz, W. H. (2001). Interventions for weight loss and weight gain prevention among youth: Current issues. Sports Medicine (Auckland, N.Z.), 31(3), 153–165. 10.2165/00007256-200131030-00002
- Gordon, K. , & Siegel, R. (2018). Identifying the best methods to assess adiposity and metabolic risk in children. Acta Paediatrica, 107(6), 921–922. 10.1111/apa.14307
- Harris, K. C. , Kuramoto, L. K. , Schulzer, M. , & Retallack, J. E. (2009). Effect of school‐based physical activity interventions on body mass index in children: A meta‐analysis. CMAJ: Canadian Medical Association Journal = Journal de l'Association Medicale Canadienne, 180(7), 719–726. 10.1503/cmaj.080966
- Jansen, W. , Borsboom, G. , Meima, A. , Zwanenburg, E. J.‐V. , Mackenbach, J. P. , Raat, H. , & Brug, J. (2011). Effectiveness of a primary school‐based intervention to reduce overweight. International Journal of Pediatric Obesity: IJPO: An Official Journal of the International Association for the Study of Obesity, 6(2–2), e70–e77. 10.3109/17477166.2011.575151
- Keleher, H. (2004). Why build a health promotion evidence base about gender? Health Promotion International, 19(3), 277–279. 10.1093/heapro/dah313
- Kremers, S. P. J. , de Bruijn, G.‐J. , Droomers, M. , van Lenthe, F. , & Brug, J. (2007). Moderators of environmental intervention effects on diet and activity in youth. American Journal of Preventive Medicine, 32(2), 163–172. 10.1016/j.amepre.2006.10.006
- Kriemler, S. , Zahner, L. , Schindler, C. , Meyer, U. , Hartmann, T. , Hebestreit, H. , … Puder, J. J. (2010). Effect of school based physical activity programme (KISS) on fitness and adiposity in primary schoolchildren: Cluster randomised controlled trial. BMJ (Clinical Research Ed.), 340, c785 10.1136/bmj.c785
- Krueger, P. M. , & Reither, E. N. (2015). Mind the gap: Race/ethnic and socioeconomic disparities in obesity. Current Diabetes Reports, 15(11), 95 10.1007/s11892-015-0666-6
- Labonté, R. (2011). Toward a post‐Charter health promotion. Health Promotion International, 26(Suppl 2), ii183–ii186. 10.1093/heapro/dar062
- Lane, S. P. , Bluestone, C. , & Burke, C. T. (2013). Trajectories of BMI from early childhood through early adolescence: SES and psychosocial predictors. British Journal of Health Psychology, 18(1), 66–82. 10.1111/j.2044-8287.2012.02078.x
- Llewellyn, A. , Simmonds, M. , Owen, C. G. , & Woolacott, N. (2016). Childhood obesity as a predictor of morbidity in adulthood: A systematic review and meta‐analysis. Obesity Reviews : An Official Journal of the International Association for the Study of Obesity, 17(1), 56–67. 10.1111/obr.12316
- Manitoba Centre for Health Policy . (2008). Construction of census income quintiles. Retrieved July 3,2019, from
- Mei, H. , Xiong, Y. , Xie, S. , Guo, S. , Li, Y. , Guo, B. , & Zhang, J. (2016). The impact of long‐termschool‐based physical activity interventions on body mass index of primary school children—Ameta‐analysis of randomized controlled trials. BMC Public Health, 16, 205 10.1186/s12889-016-2829-z
- Mikkonen, J. , & Raphael, D. (2010). Social determinants of health: The Canadian facts. Toronto: York University School of Health Policy and Management.
- National Center for Health Statistics . (2009). Clinical growth charts. Retrieved from Centers for Disease Control and Prevention website:
- Navarro, A. , Voetsch, K. , Liburd, L. , Bezold, C. , & Rhea, M. (2006). Recommendations for future efforts in community health promotion: Report of the National Expert Panel on community health promotion. Atlanta, GA.
- Ogden, C. L. , Carroll, M. D. , Kit, B. K. , & Flegal, K. M. (2014). Prevalence of childhood and adult obesity in the United States, 2011‐2012. JAMA, 311(8), 806–814. 10.1001/jama.2014.732
- Oosterhoff, M. , Joore, M. , & Ferreira, I. (2016). The effects of school‐based lifestyle interventions on body mass index and blood pressure: A multivariate multilevel meta‐analysis of randomized controlled trials. Obesity Reviews : An Official Journal of the International Association for the Study of Obesity, 17(11), 1131–1153. 10.1111/obr.12446
- Organisation for Economic Cooperation and Development . (2014). Obesity update. Retrieved July 22,2016, from
- Ostlin, P. , Eckermann, E. , Mishra, U. S. , Nkowane, M. , & Wallstam, E. (2006). Gender and health promotion: A multisectoral policy approach. Health Promotion International, 21(Suppl 1), 25–35. 10.1093/heapro/dal048
- Palmieri, V. , Henshaw, M. , Carter, J. , & Chowdhury, S. (2018). Assessing truncal obesity in predicting cardiometabolic risk in children: Clinical measures versus dual‐energyX‐ray absorptiometry. Acta Paediatrica, 107(6), 1065–1069. 10.1111/apa.14175
- Reilly, J. J. , & Kelly, J. (2011). Long‐term impact of overweight and obesity in childhood and adolescence on morbidity and premature mortality in adulthood: Systematic review. International Journal of Obesity (2005), 35(7), 891–898. 10.1038/ijo.2010.222
- Roberts, K. C. , Shields, M. , de Groh, M. , Aziz, A. , & Gilbert, J.‐A. (2012). Overweight and obesity in children and adolescents: Results from the 2009 to 2011 Canadian Health Measures Survey. Health Reports, 23(3), 37–41. Retrieved from.
- Ronsley, R. , Lee, A. S. , Kuzeljevic, B. , & Panagiotopoulos, C. (2013). Healthy Buddies™ reduces body mass index z‐score and waist circumference in Aboriginal children living in remote coastal communities. The Journal of School Health, 83(9), 605–613. 10.1111/josh.12072
- Rubin, D. (1987). Multiple imputation for nonresponse in surveys. NewYork: John Wiley & Sons.
- Santos, R. , Durksen, A. , Rabbanni, R. , Chanoine, J. P. , Lamboo, M. , Mayer, T. , & McGavock, J. (2014a). Effectiveness of peer‐based healthy living lesson plans on anthropometric measures and physical activity in elementary school students: A cluster randomized trial. JAMA Pediatrics, 168(2168‐6211(Electronic)), 330–337.
- Santos, R. , Durksen, A. , Rabbanni, R. , Chanoine, J.‐P. , Lamboo Miln, A. , Mayer, T. , & McGavock, J. M. (2014b). Effectiveness of peer‐based healthy living lesson plans on anthropometric measures and physical activity in elementary school students: A cluster randomized trial. JAMA Pediatrics, 168(4), 330–337. 10.1001/jamapediatrics.2013.3688
- Sassi, F. (2010). Obesity and the economics of prevention. 10.1787/9789264084865-en
- Senate Committee on Social Affairs, S.and T . (2016). Obesity in Canada, a whole‐of‐society approach for a healthier Canada. Retrieved from
- Shields, M. , & Tjepkema, M. (2006). Regional differences in obesity. Health Reports, 17(3), 61–67 Retrieved from.
- Sobol‐Goldberg, S. , Rabinowitz, J. , & Gross, R. (2013). School‐based obesity prevention programs: A meta‐analysis of randomized controlled trials. Obesity (Silver Spring, Md.), 21(12), 2422–2428. 10.1002/oby.20515
- Stock, S. , Miranda, C. , Evans, S. , Plessis, S. , Ridley, J. , Yeh, S. , & Chanoine, J.‐P. (2007). Healthy Buddies: A novel, peer‐led health promotion program for the prevention of obesity and eating disorders in children in elementary school. Pediatrics, 120(4), e1059–e1068. 10.1542/peds.2006-3003
- Stone, E. J. , McKenzie, T. L. , Welk, G. J. , & Booth, M. L. (1998). Effects of physical activity interventions in youth. Review and synthesis. American Journal of Preventive Medicine, 15(4), 298–315. Retrieved from.
- Sweeting, H. N. (2008). Gendered dimensions of obesity in childhood and adolescence. Nutrition Journal, 7, 1 10.1186/1475-2891-7-1
- The Honourable Wilbert Joseph Keon ‐ Chair, & The Honourable Lucie Pépin ‐ Deputy Chair . (2009). A healthy, productive Canada: A determinant of health approach. Ottawa.
- The National Survey of Children's Health . (2011). The health and well‐being of children in rural areas: A portrait of the nation 2007. Rockville, MD.
- Tu, A. W. , Mâsse, L. C. , Lear, S. A. , Gotay, C. C. , & Richardson, C. G. (2015). Body mass index trajectories from ages 1to 20: Results from two nationally representative canadian longitudinal cohorts. Obesity (SilverSpring, Md.), 23(8), 1703–1711. 10.1002/oby.21158
- van Stralen, M. M. , Yildirim, M. , te Velde, S. J. , Brug, J. , van Mechelen, W. , Chinapaw, M. J. M. , & ENERGY‐consortium . (2011). What works in school‐based energy balance behaviour interventions and what does not? A systematic review of mediating mechanisms. International Journal of Obesity (2005), 35(10), 1251–1265. 10.1038/ijo.2011.68
- Verrotti, A. , Penta, L. , Zenzeri, L. , Agostinelli, S. , & De Feo, P. (2014). Childhood obesity: prevention and strategies of intervention. A systematic review of school‐based interventions in primary schools. Journal of Endocrinological Investigation, 37(12), 1155–1164. 10.1007/s40618-014-0153-y
- Waters, E. , de Silva‐Sanigorski, A. , Hall, B. J. , Brown, T. , Campbell, K. J. , Gao, Y. , … Summerbell, C. D. (2011). Interventions for preventing obesity in children. The Cochrane Database of Systematic Reviews, 12, CD001871 10.1002/14651858.CD001871.pub3
- World Health Organization . (2000). Obesity: Preventing and managing the global epidemic: Report of a WHO consultation. In WHO Technical Report Series(Vol. 894). Retrieved from
- World Health Organization . (2008). Waist circumference and waist‐hip ratio: Report of a WHO expert consultation. Geneva, Switzerland.
- Yu, B. N. , Protudjer, J. L. P. , Anderson, K. , & Fieldhouse, P. (2010). Weight status and determinants of health in Manitoba children and youth. Canadian Journal of Dietetic Practice and Research: A Publication of Dietitians of Canada = Revue Canadienne de La Pratique et de La Recherche en Dietetique: Une Publication des Dietetistes Du Canada, 71(3), 115–121. 10.3148/71.3.2010.115
Source: PubMed